ORDER

SRI RAMACHANDRA.M.S,PRESIDENT

1. The complainants files a complaint with this Commission under Section 35 of the Consumer Protection Act of 2019 with a direction to OP to pay a sum of  Rs.15,82,898/- along with interest at 18% p.a. and pay Rs.15,00,000/-  towards compensation and  Rs.3,00,000/- for legal expenses and such other reliefs.

2.  The following are the complaint's key facts:

This is the case of the complainant that Complainant’ husband on 10.03.2021 had obtained a housing loan from Aadhar HousingFinance Ltd. for construction of house in his plot to the tune of Rs.15,82,899/-. The tenure of the loan is 15 years and Nagasheshaiah was bound to pay Rs.20,815/- towards EMI. As per the terms and conditions of the bank the complainant has obtained life insurance policy from the OP on12.03.2021 and life insurance policy covers sum assured by OP insurance policy is Rs.15,82,899/-, the coverage term was upto 10 years commencing form 17.03.2021 to 16.03.2031 and the premium of Rs.64,000.47/- is also paid by the complainant to the insurance company. At the time of availing the insurance policy the policy holder Sri Naga Sheshaiah nominated complainant as nominee to the insurance policy. The policy number is GC00038.

3. It is further case of the complainant that in the month of May 2021 the policy holder Sri Nagasheshaiah, husband of the complainant has suffering from various symptoms like loss of breath and severe joint pain in the body, when he was admitted to the Sri Arogya hospital at Bengaluru, wherein he has treated as inpatient, when the tests were conducted, it is found that the policy holder was suffering from Covid-19 and thus on 09.05.2021 the policy holder Nagasheshaiah passed away leaving behind the complainant and his two children. As per death summary issued by Sri Arogya hospital, report indicates that the cause of death is  due to ACUTE MI WITH PNEUMONIA. Thereafter obtaining all the required documents when the complainant who is the nominee of the said policy has approached the OP insurance company for the settlement of the insurance claim amount. The OP company has rejected the claim of the complainant by assigning the reason the policy holder Late Nagasheshaiah as he was suffering from Diabetes which is prior to obtaining of the said policy, as this fact is not disclosed at the time of availment of the policy, it amounts to violation of the terms and conditions of the policy which resulted the OP denying the settlement claim of the complainant. Aggrieved by the act of the OP Company the complainant was forced to file present complaint sought for the relief of insurance claim amount along with other reliefs as prayed in the complaint.

4. Notice to OP-duly served, represented by counsel and filed detailed written version and also produced relevant documents in support of their contention. Despite of sufficient opportunity the OP have not chosen to file chief examination affidavit. Hence, affidavit evidence of OP is taken as not filed.

5. The complainant filed chief-examination affidavit along with relevantdocuments  in support of their pleadings with   citations.

6. Heard arguments. The matter is reserved for order.

7. The points that arise for our consideration are;

1. Whether the Complainant prove that there is deficiency in service on the part of the OP as alleged in the complaint and thereby prove that he is entitle for the relief sought?
2. What order?

8. The findings on the above points are as under:

Point No.1                :       Partly in Affirmative

Point No.2                :       As per final order

REASONS

9. POINT NO.1:-Complainant’ husband on 10.03.2021 had obtained a housing loan from Aadar Housing  Finance Ltd. for the construction of house in his plot to the tune of Rs.15,82,899/-. The tenure of the loan is 15 years. As per the terms and conditions of the bank the complainant has obtained life insurance policy from the OP on12.03.2021 and life insurance policy covers sum assured by OP insurance policy is Rs.15,82,899/-, the coverage term was upto 10 years commencing form 17.03.2021 to 16.03.2031 and the premium of Rs.64,000.47/- is also paid by the complainant to the insurance company. At the time of availing the insurance policy the policy holder Sri Naga Sheshaiah nominated complainant as nominee to the insurance policy. The policy number is GC00038.

10. It is the case of the complainant that in the month of May 2021 the policy holder Sri Nagasheshaiah, husband of the complainant was suffering from various symptoms like loss of breath and severe joint pain in the body, when he was admitted to the Sri Arogya hospital at Bengaluru, wherein he has treated as inpatient, when the tests were conducted, it is found that the policy holder was suffering from Covid-19 and thus on 09.05.2021 the policy holder Nagasheshaiah passed away leaving behind the complainant and his two children. As per death summary issued by Sri Arogya hospital, report indicates that the cause of death is due to ACUTE MI WITH PNEUMONIA. Thereafter obtaining all the required documents when the complainant who is the nominee of the said policy has approached the OP insurance company for the settlement of the insurance claim amount. The OP company has rejected the claim of the complainant by assigning the reason that the policy holder Late Nagasheshaiah as he was suffering from Diabetes which is prior to obtaining of the said policy, as this fact is not disclosed at the time of availment of the policy, it amounts to violation of terms and conditions of the policy which resulted the OP denying the settlement claim of the complainant claim. Aggrieved by the act of OP company the complainant was forced to file present complaint and sought for the relief of insurance claim amount along with other reliefs as prayed in the complaint.

11. The OP represented by counsel has filed detailed version, they denied entire complaint allegations as false and also denied any deficiency on their part during the course of service to the complainant. Their specific contention for rejection of the insurance claim amount is non-disclosure of material facts as well as suppression of material facts that complainant was suffering from diabetic prior to availment of said insurance policy. As  this fact of non-disclosure is clear violation of the terms and conditions of the insurance contract, which is entered between both the parties. By contending the same the OP has refused to honour the claim of the complainant as there is clear violation of terms and conditions of the policy by the policy holder. By agitating the OP denied to settle the claim of the complainant and on this ground they pray for dismissal of the complaint.

12. The complainant filed chief examination affidavit by reiterating the complaint averments and also produced some relevant documents in support of their plea. The issuance of the policy by the OP Company and its validity is not at all disputed. The dispute between the complainant and OP Company is as there is a clear violation of policy terms and conditions by the policy holder. The OP company contention is that the claim of the complainant is not legally payable as the complainant claim was rightly rejected on the ground of suppression of material facts, non-disclosure of material facts. As the policy holder fails to disclose the aforesaid facts as it amounts to clear violation of the terms and conditions of the policy. The OP Company declined to settle the claim of the complainant. On these grounds, the commission observe as follows, the Hon’ble Supreme Court of India and also Hon’ble National Disputes Redressal Commission, New Delhi, in their several verdicts have laiddown the ratio which needs to be followed by the company while dealing with such claims. The Apex court of India have held on the fact the judgment rendered by the Hon’ble Supreme court in Civil Appeal No.3397/2020 between the Branch Manager, Bajaj Alliance Insurance Co. Ltd. & others V/s Dalbir Kaur and Hon’ble National Commission, New Delhi, on the point of Hypertension in a case between Mamata Kumar V/s Bharathi Axa Life Insurance Co. , which is alleged in 2016(1) CPJ page 613 insured having an hypertension does not amount to suppression of material facts as it being a life style disease. It is also discussed in the case that it has been clearly mentioned that hypertension and diabetic are lifestyle diseases and it do not amount to suppression of material illness. The principles which is laid down in the judgment is Diabetic and Hypertension cannot be considered  as disease which is held as life style of the people and the insurance company cannot reject any claim of policy for the reasons, that the insured is suffering from diabetic and hypertension.

13. In view of the above discussion and by considering the facts of the complaint and also by taking note of the ratio laid down by the Apex Court of India we have no hesitation to hold that it is a clear case of deficiency on the part of OP company while dealing with the insurance claim of the complainant, for which liability could be casted upon the company to pay the insurance claim of the complainant along with other reliefs which is granted in the complaint.

14. In view of the above discussion, by considering the contention of both parties and also ratio laid down by the Hon’ble Supreme Court of India and Appellate Authority it is held that rejection of complainant claim is not justified, it is to be held as bad in law. When such being the case, the claim of the complainant is hereby allowed and at the same time OP is held liable to settle the legitimate insurance claim of the complainant which is covered under the said policy by indemnifying the insurance contract which is entered between the parties.Accordingly,  the Point No.1 we answer Partly in Affirmative.

15. POINT NO.2:- In the result, we passed the following:

                             ORDER

1. Complaint is allowed in part.
2. The OP is  directed to settle the insurance claim amount of Rs.15,82,898/- along with interest at the rate of 8% p.a. from the last date of rejection till settlement is made  to the complainant.
3. The OP is  further directed to pay a sum of  Rs.10,000/- as compensation towards deficiency of service and Rs.5,000/- towards litigation charges. If OP fails to comply the order within 45 days from the date of order, compensation amount and cost of litigation shall carry interest at 6% p.a. for non-compliance of the order.

4. Furnish free copy of this order to both the parties. 

 (Dictated to the Stenographer, got it transcribed, typed by him and corrected by me, then pronounced in the Open Commission on 31^stMay 2023)

(RAMACHANDRA M.S.)

PRESIDENT

(NANDINI H KUMBHAR)          (CHANDRASHEKAR S.NOOLA)       

 MEMBER                                  MEMBER

Witness examined on behalf of the complainant by way of affidavit:Smt.D.Nagamani-who being the complainant

Documents produced by the complainant:

Witness examined on behalf of the OP by way of affidavit:Nil

Documents produced by the OP:

(RAMACHANDRA M.S.)

PRESIDENT

(NANDINI H KUMBHAR)          (CHANDRASHEKAR S.NOOLA)

         MEMBER                                     MEMBER

SKA*